Provider Demographics
NPI:1215043807
Name:DAVIDSON, ELLIOT B (MD)
Entity Type:Individual
Prefix:
First Name:ELLIOT
Middle Name:B
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 WABASH AVE
Mailing Address - Street 2:#301
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44307-2433
Mailing Address - Country:US
Mailing Address - Phone:330-344-6047
Mailing Address - Fax:330-344-6042
Practice Address - Street 1:400 WABASH AVE
Practice Address - Street 2:#301
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44307-2433
Practice Address - Country:US
Practice Address - Phone:330-344-6047
Practice Address - Fax:330-344-6042
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35049124207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3600271OtherMEDICARE GROUP #
OH0542167Medicaid
OH1841239274OtherPARTNERS PHYSICIAN GROUP TYPE 2 NPI #
OH0290886OtherMEDICAID GROUP #
OH1821035940OtherAGMC TYPE 2 NPI #
OH0290886OtherMEDICAID GROUP #
OH1821035940OtherAGMC TYPE 2 NPI #